{% extends "myapp/base.html" %}

{% block main_body %}
   <!-- Content Header (Page header) -->
   <section class="content-header">
    <h1>
      病人信息管理
      <small>电子病历系统</small>
    </h1>
    <ol class="breadcrumb">
      <li><a href="#"><i class="fa fa-dashboard"></i> 首页</a></li>
      <li class="active">病人信息管理</li>
    </ol>
  </section>

  <!-- Main content -->
  <section class="content container-fluid">

    <div class="row">
<!--        request.GET.get('IDname','')-->
      <div class="col-xs-12">
        <div class="box">
          <div class="box-header">
              <h2 class="box-title"> <span class="glyphicon glyphicon-calendar" aria-hidden="true">编辑病人信息</h2>
          </div>
          <!-- /.box-header -->
          <!-- form start -->
          <form class="form-horizontal" action="{% url 'myapp_patientinfo_update' %}" method="post">
            {% csrf_token %}
            <div class="box-body">

              <div class="form-group">
                <label class="col-sm-2 control-label">住院号：</label>

                <div class="col-sm-4">
                  <input type="text" name="hspid" readonly value="{{patientinfo.hspid}}" class="form-control"  placeholder="住院号">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">病人姓名：</label>

                <div class="col-sm-4">
                  <input type="text" name="name" value="{{patientinfo.name}}" class="form-control"  placeholder="病人姓名">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">性别：</label>

                <div class="col-sm-4">
                  <input type="text" name="gender" value="{{patientinfo.gender}}" class="form-control"  placeholder="性别" >
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">科室：</label>

                <div class="col-sm-4">
                  <input type="text" name="departname" value="{{patientinfo.departname}}" class="form-control" placeholder="科室"  >
                </div>
              </div>

                <div class="form-group">
                <label  class="col-sm-2 control-label">负责医生：</label>

                <div class="col-sm-4">
                  <input type="text" name="doctorname" value="{{patientinfo.doctorname}}" class="form-control"  placeholder="负责医生">
                </div>
              </div>

                <div class="form-group">
                <label  class="col-sm-2 control-label">床位信息：</label>

                <div class="col-sm-4">
                  <input type="text" name="bedid" value="{{patientinfo.bedid}}" class="form-control"  placeholder="床位信息">
                </div>
              </div>

                <div class="form-group">
                <label  class="col-sm-2 control-label">入院时间：</label>

                <div class="col-sm-4">
                  <input type="text" name="inhsptimes" value="{{patientinfo.inhsptimes}}" class="form-control"  placeholder="入院时间">
                </div>
              </div>

               <div class="form-group">
                <label  class="col-sm-2 control-label">入院诊断：</label>

                <div class="col-sm-4">
                  <input type="text" name="inhspdiagnose" value="{{patientinfo.inhspdiagnose}}" class="form-control"  placeholder="入院诊断">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">病区：</label>

                <div class="col-sm-4">
                  <input type="text" name="departzone" value="{{patientinfo.departzone}}" class="form-control"  placeholder="病区">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">MRID：</label>

                <div class="col-sm-4">
                  <input type="text" name="mrid" value="{{patientinfo.mrid}}" class="form-control"  placeholder="MRID">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">身份证号：</label>

                <div class="col-sm-4">
                  <input type="text" name="idcardno" value="{{patientinfo.idcardno}}" class="form-control"  placeholder="身份证号">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">社保：</label>

                <div class="col-sm-4">
                  <input type="text" name="medinsurancetype" value="{{patientinfo.medinsurancetype}}" class="form-control"  placeholder="社保">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">社保号：</label>

                <div class="col-sm-4">
                  <input type="text" name="medinsuranceid" value="{{patientinfo.medinsuranceid}}" class="form-control"  placeholder="社保号">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">入院种类：</label>

                <div class="col-sm-4">
                  <input type="text" name="inhsptype" value="{{patientinfo.inhsptype}}" class="form-control"  placeholder="入院种类">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">病症：</label>

                <div class="col-sm-4">
                  <input type="text" name="illness" value="{{patientinfo.illness}}" class="form-control"  placeholder="病症">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">季节：</label>

                <div class="col-sm-4">
                  <input type="text" name="illseason " value="{{patientinfo.illseason}}" class="form-control"  placeholder="季节">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">婚姻情况：</label>

                <div class="col-sm-4">
                  <input type="text" name="marriage" value="{{patientinfo.marriage}}" class="form-control"  placeholder="婚姻情况">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">国家：</label>

                <div class="col-sm-4">
                  <input type="text" name="nation" value="{{patientinfo.nation}}" class="form-control"  placeholder="国家">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">职业：</label>

                <div class="col-sm-4">
                  <input type="text" name="profession" value="{{patientinfo.profession}}" class="form-control"  placeholder="职业">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">地址：</label>

                <div class="col-sm-4">
                  <input type="text" name="address" value="{{patientinfo.address}}" class="form-control"  placeholder="地址">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">公司：</label>

                <div class="col-sm-4">
                  <input type="text" name="corporation" value="{{patientinfo.corporation}}" class="form-control"  placeholder="公司">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">联系人姓名：</label>

                <div class="col-sm-4">
                  <input type="text" name="contactsname" value="{{patientinfo.contactsname}}" class="form-control"  placeholder="联系人姓名">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">与病人关系：</label>

                <div class="col-sm-4">
                  <input type="text" name="relation" value="{{patientinfo.relation}}" class="form-control"  placeholder="与病人关系">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">联系电话：</label>

                <div class="col-sm-4">
                  <input type="text" name="contactsphone" value="{{patientinfo.contactsphone}}" class="form-control"  placeholder="联系电话">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">邮编：</label>

                <div class="col-sm-4">
                  <input type="text" name="postcode" value="{{patientinfo.postcode}}" class="form-control"  placeholder="邮编">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">出生日期：</label>

                <div class="col-sm-4">
                  <input type="text" name="birthday" value="{{patientinfo.birthday}}" class="form-control"  placeholder="出生日期">
                </div>
              </div>

              <div class="form-group">
                <label  class="col-sm-2 control-label">记录时间：</label>

                <div class="col-sm-4">
                  <input type="hsptime" name="contactsname" value="{{patientinfo.contactsname}}" class="form-control"  placeholder="记录时间">
                </div>
              </div>

              <div class="form-group">
                  <div class="col-sm-offset-2 col-sm-10">
                    <button type="submit"  class="btn btn-primary">保 存</button>
                  </div>
              </div>
            </div>
            <!-- /.box-footer -->
          </form>
        </div>
        <!-- /.box -->
      </div>
    </div>

  </section>
  <!-- /.content -->
{% endblock %}